Genitourinary Pathology Case 4
Part 1
The patient is a 59
year old male with a history of endstage ischemic cardiomyopathy due to
atherosclerosis and exacerbated by diabetes mellitus. The patient was on the
list for cardiac transplant when he developed markedly diminished urinary
output with a rising BUN and creatnine and a 10 lb weight gain. He was admitted
on
CXR showing
heart failure
|
Lab Name |
Result/Unit |
Ref. Interval |
|
White Blood Cell
Count |
4.1 K/uL |
3.20-10.6 |
|
Hematocrit |
39.5 % |
34.3-45.2 |
|
Platelets |
262 K/uL |
177-406 |
|
|
|
|
|
Na |
137 mmol/L |
136-144 |
|
K |
4.8 mmol/L |
3.3-50 |
|
Cl |
104 mmol/L |
98-107 |
|
Carbon Dioxide |
23 mmol/L |
22-29 |
|
Glucose |
107 mg/dL |
64-128 |
|
Blood Urea Nitrogen |
64 mg/dL |
7-20 |
|
Creatinine |
3.6 mg/dL |
0.7-1.1 |
1. What is pre-renal failure?
2. Why did this man gain 10 pounds?
Part 2
On
|
Lab Name |
Result/Unit |
|
Admission Vitals |
|
|
Heart Rate |
80 |
|
Blood Pressure |
83/60 |
|
Respiratory Rate |
22 |
|
Date |
Bun |
Creatinine |
|
|
128 mg/dL |
5.6 mg/dL |
|
|
115 mg/dL |
4.6 mg/dL |
|
|
105 mg/dL |
3.5 mg/dL |
|
|
90 mg/dL |
2.7 mg/dL |
|
|
76 mg/dL |
2.3 mg/dL |
|
|
54 mg/dL |
1.7 mg/dL |
|
|
63 mg/dL |
1.6 mg/dL |
|
|
52 mg/dL |
1.5 mg/dL |
|
|
49 mg/dL |
1.4 mg/dL |
|
|
43 mg/dL |
1.3 mg/dL |
|
|
42 mg/dL |
1.9 mg/dL |
Chest X-ray
1. Why did the dobutamine improve the BUN and creatnine?
2. What was the underlying cause of death?
Part 3
An autopsy was
performed:
|
|
Thoraco-abdominal
incision with LVAD |
|
|
Discordant size of
kidneys |
|
|
Kidneys opened seen
from anterior with atherosclerosis of aorta |
|
|
Low power view of
kidney |
|
|
Medium power
showing sclerotic glomeruli |
|
|
Diabetic
vasculopathy in the kidney |
|
|
Diabetic
arteriosclerosis |
|
|
Cross section of
coronary artery |
|
|
Old MI with
hypertrophy of myocytes |
|
|
Subacute MI with
resolution |
1. What was the cause of death?
2. Was heart failure the only cause of renal disease in this
patient?
3. What risk factors did this patient have for renal
disease?
Part 4
Using all of the
information you have gathered from the chart, prepare a presentation about this
case as you would for attending rounds with a concise summary of the history,
physical findings, labs and x-rays. Your presentation should be about 5 minutes
long. A copy of your presentation needs to be handed in to your facilitator by
the end of the lab on
Incorporate the
following basic questions/answers/points into your report:
1. How does atherosclerosis affect the kidney and its
function, discuss both small and large vessel disease?
2. What are the sequelae of renal artery stenosis?
3. How can renal artery stenosis be diagnosed and treated?
Operative Report June 11, 2002
Clinic Note, March
28, 2002
The patient is a 59-year-old male with chronic congestive heart failure who has now received maximal medical therapy. He is referred for a possible candidacy of mechanical ventricular assistance for his failing heart.
His cardiac history dates back to 1985 when he began having symptoms of heart failure. He was treated medically 1997. At that time he was felt to have ischemic heart disease with very little viable myocardium. He underwent a single vessel coronary bypass five years ago. Since that time he has undergone further medical treatment for his heart failure. He has had gradually worsening renal function, probably related to poor perfusion of his kidneys. He has been offered home dobutamine on several occasions, but has refused this due to a poor quality of life. He currently does not wear oxygen, and gets occasional substernal chest tightness treated with sublingual nitroglycerin. He is only able to walk short distances before having to stop to rest. He has been plagued by fluid retention, including lower extremity edema as well as ascites. He has not undergone any further cardiac catheterizations due to his poor renal function.
Past medical history is significant for ischemic cardiomyopathy as described above. He underwent cholecystectomy and appendectomy approximately 20 years ago. In addition, he has insulin-dependent diabetes and chronic renal insufficiency with creatinine ranging from 3-4. Current medications include Zaroxolyn 5 mg daily, Lasix 60 mg daily, potassium 20 mEq daily, Amiodarone 400 mg daily, Lipitor 20 mg daily, Coumadin 2.5 mg four days a week, and 5 mg three days a week, Prilosec 20mg daily, aspirin 500 mg daily, Flonase and Ventolin inhalers, p.r.n. sublingual nitroglycerin, and insulin 15 units of NPH and 15 units of regular bid with a sliding scale as needed. He has allergies to streptokinase, sulfa, and Phenergan.
Family history is significant for heart disease, hypertension, and cancer. His father died with both heart disease and cancer. His mother is currently living. He has three living siblings. He has a previous history of smoking but quit four years ago. He denies any alcohol consumption. Review of systems is remarkable for weight loss, which he has done intentionally, and has lost approximately 30 pounds over the last six months. He also complains of shortness of breath with exertion, occasional nausea and diarrhea, difficulty urinating as well as nocturia, and occasional joint pain.
Physical examination reveals temperature 98.2, pulse 83, blood pressure 78/52, respirations 16, weight 220.7 lb. With a height of 5’10”. Head and neck exam is within normal limits without cervical adenopathy, visible jugular venous distension, or carotid bruits. The lungs have scattered basilar crackles but no wheezes or rhonchi. The heart is regular without murmurs or gallops. The sternal wound has healed well but the sternum appears separated in the midline from a chronic dehiscence. However, this does not cause pain or tenderness on exam. Abdomen is protuberant and mildly obese, but nontender and without palpable masses. Extremities have approximately 1+ edema. There are palpable pulses in both the femoral and the pedal positions, stronger in the left foot than the right. Neurologic exam is nonfocal.
Data, which I
independently reviewed, include the patient’s previous medical records with
findings as described above. Most recent laboratories include a BMP from
Impression: The patient is a pleasant middle-aged male who appears somewhat older than his stated age. He has Class IV heart failure. He has received maximal medical therapy. His higher creatinine was likely due to over diureses, and with decrease in diuretic dose, his creatinine has decreased to less than 3. However, he appears to walk a very fine line between fluid overload and renal failure. I think he would be an acceptable candidate for permanent LVAD placement.
TOP
Admission H&P May 20, 2002
CC: nausea, vomiting, diarrhea, episode of right-sided numbness
HPI: Pt is a 59 y/o male with CAD, CHF, ischemic cardiomyopathy, paroxysmal a-fib, DM, CRI, hyperlipidemia who presented to heart failure clinic today with a 1-wk h/o n/v/d and generalized malaise. Additionally, he describes an episode of right-sided facial, arm and thorax numbness occurring last night during sleep.
In clinic, pt was noted to have about a 10-lb wt gain since last visit 5/8. He has noted worsened dyspnea over baseline, for which he uses 2L NC O2 intermittently. He denies orthopnea, PND.
PMH:
1.
2. CHF. Pt had bi-vent pacer placed. Last ECHO: EF <20.
3. A-fib, paroxysmal.
4. DM x4 yrs, insulin-requiring.
5. Gangrene in left knee several years ago requiring surgical debridement.
6. Chronic Renal Insufficiency, baseline Cr 2-3.
7. Anemia of chronic disease.
8. Hyperlipidemia.
9. GERD
10. OA
11. Hypotension.
PSH: chole, appy, knee debridement as above,
FH: +CAD
SH: He has a 75 pk-yr smoking hx, quit 4 yrs ago. No EtOH/drugs.
Allergies: streptokinase- anaphylaxis, sulfa- anxiety, Phenergan- itching, anxiety
PE: VS- 37.0 105/62 80 20 99% 2L
Gen- alert, slightly dyspneic with speech, nad
HEENT- perrla, eomi, mmm, op clear
Neck- supple, no lad, jvp ~9cm (?), no carotid bruits
CV- unable to palpate pmi, heart sounds distant, unable to evaluate
Resp- ctap, no w/r/r
Abd- ecchyomses noted abd wall, soft, nt/nd, +liver edge with insp, +bs
Ext- warm, 3+ edema below knee, tr above, pulses 1/4 carotid, radial, dp/pt, femoral 2+
MS- limited ROM bilat hands, unable to make fist, R 4th mcp subluxation, o/w good ROM throughout, tenderness over SI joints, left trochanteric bursitis, quite tender to touch, no erythema
Skin- petechiae of forearms, ecchymosis abd wall as above, venous stasis changes BLE
Neuro- cn ii-xii intact, no grip strength with inability to make fists 2/2 OA, right arm flexion 4/5, left leg flexion limited by hip pain, o/w strength 5/5, sensation grossly intact to light touch, DTRs 2/4 throughout, gait and cerebellar function not tested
Labs- CBC: 4.1/39.5/262 chem.: 137/4.8/104/23/64/3.6/107
AST 56, alt 31, AP 408, TB 1.2
INR 7.0, PTT 84
A/P:
1. CV:
-CHF exacerbation with 10-lb wt gain,
increased dyspnea. Given pt's high doses loop diuretics, will begin nesiritide
gtt, monitor I/Os, daily wts, fluid restrict
-A-fib with symptomatology including increased fatigue, n/v/d. Will cont quinidine, amio for now. Check quinidine level in a.m. as previous level sub therapeutic prior to dosing frequency increase to tid.
-Hypotension. Pt has low BP at baseline, SBP generally <110. Will monitor with diuretics, nesiritide. Hold for SBP <85.
-CAD. Significant h/o ischemic heart disease. Will check serial trops to r/o MI.
2. DM: Cont outpatient lente and place on SSI.
3. CRI: Baseline Cr reported as 2-3, now 3.6. This may worsen with diuresis.
FULL CODE
Ventricular Rate 125 BPM
Atrial Rate 125 BPM
P-R Interval ms
QRS Duration 112 ms
QT 110 ms
QTc 158 ms
P Axis
R Axis -93 degrees
T Axis 0 degrees
Demand pacemaker;
interpretation is based on intrinsic rhythm
Discharge
Summary 5-29-02
REASON FOR ADMISSION: Heart failure exacerbation.
DIAGNOSTIC: Right heart catheterization, heart transplant/LVAD evaluation.
HISTORY: For a complete history and physical please
see the H&P dated
ALLERGIES: Streptokinase, Phenergan and sulfa.
HOSPITAL COURSE:
1. The patient was admitted in fair condition and started on nesiritide to help with diuresis, increased glomerular filtration rate and also help with preload and afterload in a patient with severe heart failure and underlying hypotension. After nesiritide was started the patient did have a very aggressive diuresis and became stable rather quickly. He also remained on his other medications, IV Lasix was administered twice daily, amiloride was started to help him retain his potassium and his Zaroxolyn was kept at his maintenance dose. His amiodarone was also increased during his hospital stay as will be mentioned in discharge medications. The patient had many laboratory tests done for heart transplant workup which will be mentioned at the end of this note.
2. Cardiovascular issues. The patient was hemodynamically unstable when he was initially admitted and then gradually became hemodynamically stable after aggressive diuresis. He had an ischemic cardiomyopathy with severe heart failure. He was euvolemic at the time of discharge and had moderately to severely compromised cardiac output. His transplant candidacy evaluation was in progress throughout his hospital stay. It was felt that the patient would require a mechanical circulatory support as a bridge to transplantation if he was accepted for transplant candidacy. He also was admitted in paroxysmal atrial fibrillation. He was in sinus rhythm at the time of discharge. His Coumadin was restarted after his right heart catheterization and he also had a supra therapeutic INR on admission likely secondary to his CHF exacerbation and hepatic congestion. His INR upon discharge was 1.7. He had known coronary artery disease, had one episode of chest pain during his hospital stay with negative cardiac enzymes and no EKG changes. There was no evidence for acute coronary syndrome during his admission.
3. Renal. The patient had chronic renal insufficiency at baseline. A 24-hour urine for creatinine clearance was obtained and will be discussed later in this note. His very poor cardiac output was likely the primary cause of the patient's renal insufficiency. Initially, the patient was diuresed with Lasix, changed to Demadex upon discharge and all the above-mentioned medications were per the heart transplant team and the medications were evaluated during his hospital stay and adjusted as needed.
DISPOSITION: He was discharged in stable condition with
close followup with an appointment on
DISCHARGE MEDICATIONS: Amiodarone 400 mg p.o. q.d., Prevacid 30 mg p.o. q.d., quinidine 324 mg p.o. t.i.d., potassium replacement 20 mEq p.o. b.i.d., magnesium oxide 400 one p.o. q.d., amiloride 5 mg p.o. q.d., Zaroxolyn 5 mg p.o. q.d., Demadex 60 mg p.o. b.i.d., methimazole 15 mg p.o. q.d., Coumadin 2.5 mg p.o. q.d., Lente insulin 13 units subcutaneous b.i.d., NovoLog sliding scale, Regular insulin subcutaneous per sliding scale protocol, aspirin 81 mg p.o. q.d. The patient was also discharged on oxygen 2 L via nasal cannula at rest and 4 L nasal cannula with activity.
Admission
H&P
The patient was seen in cardiothoracic clinic today. The patient was noted to have a rising BUN and creatinine, as well as markedly diminished urine output. The patient has had significantly worsening symptoms of CHF.
Vitals: 80, 82/60, 22, 35.9, 100% 2 L NC
Exam: elderly appearing male
HEENT: NC/AT, anicteric
Chest: find crackles
CV: RRR, (+) S3
Abd: soft, enlarged liver span
Ext: changes c/w chronic venostasis
Skin: warm, dry
Labs: CBC: 3.66/35.6/344
Chem: 135/3.3/92/29/121/5.5/61
Alk Phos: 477, AST: 48, ALT: 17, Ca++ : 9.9, T. Prot.: 7.7, Alb: 3.6, T.Bili: 1.4
A/P: Chronic class IV CHF, acutely decompensated. Will attempt to improve patient’s symptoms with IV dobutamine, follow lab work and urine output. As patient may not be able to wean off Dobutamine, will tentatively schedule for LVAD.
Progress Note
Pt recently approved for heart transplant, conditional renal function, level VII. Pt scheduled to have BiVAD on June 11. To improve his symptoms he was placed on IV Dobutamine 5mcg/kg/min.
Overnight pt did well, but this am had V fib arrest, resuscitated with chest compressions and shocked 200J x1 which resuscitated pt. The 1st code last about 30 minutes, pt almost intubated but aroused when converted. Moved to MICU and went into V Tac again, shocked with 200 and 300J, he then returned to paced rhythm, total code= 10 minutes. Placed on lidocaine 1mg/min drip. Pt has AICD, but didn't fire because rate not high enough. Currently, pt c/o fatigue but no chest pain or shortness of breath.
Home Meds:
Epogen 6000 units q week
Amiloride 5mg qd
MgOx 400mg qd
Demadex 60mg bid
Coumadin 2.5 mg qd
Tylenol 1000mg bid/tid
KCl 20mEq bid
Asa 325 qd
Reg insulin 10 q am, qpm
Lente 10 qam, qpm
NovoLog ISS
Lipitor 20mg qd
Flonase bid
Ventolin BID
Zaroxolyn 5mg qd
Amiodarone 400mg qd
Quinidine 324mg tid
Tapazole 5mg tid
Hospital Meds Currently:
Lidocaine 1mg/min
Dobutamine 3mcg/kg/min
Epogen 5000 units sq qd
Amiloride 5mg po qd
Lipitor 20mg po qd
Quinidine 324mg po tid
Flonase
Ventolin
Lente 10U qhs
Reg Insulin 10 q am, pm
MgOx 400 qd
Labs: ABG @ 0719 7.448/27.6/208 HCO3 18.8
BMP: 131/3.0/93/25/127/4.9, Glu 145
PT /INR 24/2.1
CBC 4.4/36.9%/348
Cardiac tracing: a fib, rate 80
Assessment: 59 yo man with decompensated heart failure scheduled for BiVAD placement next week. Pt had two episodes of V tach/fib this am requiring defibrillation. Pt currently stable. Vtach/fib likely 2/2 hypokalemia. Does not appear to be fluid overloaded.
Plan:
1. Cardiac:
CHF- Does not need diuresis. Continue IV dobutamine @ 3mcg/kg/min until K is within normal range, and then increase to 5mcg/kg/min.
Arrhythmia- Continue IV lidocaine @1mg/min. Continue amiodarone, if pt has many PVCs or more arrhythmias then change to IV.
2. Renal: would like BUN/Cr to be decreased. With dobutamine should have increased perfusion and likely Cr will fall. Continue Epogen qd.
3. Code: full.
Operative
Report June 11, 2002
PREOPERATIVE DIAGNOSIS: Left ventricular failure.
POSTOPERATIVE DIAGNOSIS: Same as above.
OPERATIONS PERFORMED: 1. Redo sternotomy.
2. Placement of HeartMate XVE left ventricular assist device.
ANESTHESIA: General endotracheal anesthesia.
INDICATIONS FOR SURGERY: The patient is a 59-year-old male who has been accepted as a candidate for heart transplantation. He was found to have severely worsening left ventricular failure with rising creatinine and had been admitted for inotropic therapy. However, due to continued symptoms of heart failure, he was felt to be a candidate for a left ventricular assist device as bridge to transplantation. Therefore, after he was medically stabilized, he was brought to the Operating Room for LVAD placement as he was significantly inotropic dependent.
He tolerated the procedure well and there were no complications. All needle, sponge and instrument counts were correct. Full dose aprotinin was utilized as an antifibrinolytic.
Total cardiopulmonary bypass time was 87 minutes. There was no aortic cross-clamp time.
CHEST XRAY – 06/11/2002
HISTORY: Line placement.
FINDINGS: Portable examination is compared to a similar study
done yesterday. An endotracheal tube has been inserted. The tip is about 3-4 cm
above the carina. The pacemaker with its multiple leads is unchanged. Swan-Ganz
catheter is now present inserted through the left jugular catheter. The tip is
in the right pulmonary artery. The patient has received a left ventricular
assist device. A left pleural effusion is present on the left side. The left
chest tube and pericardial tube have also been inserted.
IMPRESSION:
SATISFACTORY POSTOPERATIVE EXAMINATION WITH ALL THE TUBES IN
EXPECTED POSITION.
TOP
Death Summary June 29, 2002
Adm Date:
Disc Date:
DISCHARGE DIAGNOSES:
Death secondary to ischemic cardiomyopathy and left heart failure treated with left ventricular assist device (LVAD) placement
PROCEDURE:
On
HOSPITAL COURSE: The patient was admitted with suspected acute renal failure coupled with chronic renal secondary to diabetes. On the second hospital day the patient went into cardiac arrest, and the patient was masked and ventilated, and CPR was performed. He had no perfusing rhythm at that time, and it was appreciated to be ventricular tachycardia on the monitor. He was shocked with 200 joules once and converted to a paced rhythm. He subsequently resumed spontaneous breathing. His ABG revealed low potassium and also magnesium was given. The patient was on dobutamine, and this was initially held. A right groin triple-lumen central line was placed.
He was then transferred to the medical intensive care unit. Dobutamine was restarted for inotropic support. The patient was in ventricular tachycardic arrest. He was shocked 200 joules, then 300 joules, and converted to a paced rhythm. He subsequently regained consciousness, and LVAD placement was performed on day 5 without complications. The patient was transferred stable to the surgical intensive care unit. On day 7, his mediastinal chest tubes were discontinued as was his Swan-Ganz catheter. His JP drain was removed on day12. He remained on antibiotics for a positive sputum culture.
The patient was
transferred to the floor on
On
pH of 6.98, PCO2 of 57, PO2 of 22.7, lactate 9.6, potassium 5.8
pH of 7.041, PCO2 of 52, PO2 of 37, lactate 11.3, potassium 6.6, and bicarbonate of 13.5
pH of 7.102, PCO2 of 24.4, PO2 of 121, lactate 13.4, potassium 8.8, and bicarbonate of 7.3
With this, the patient failed to improve. The patient was maintained on high dose epinephrine. The family was notified of the circumstances, and they decided to withdraw support.
Autopsy Report 07/01/2002
AUTOPSY CAUSE OF DEATH: Cardiomyopathy
OTHER CONDITIONS: Left ventricular assist device, atrophic left kidney,
Renal failure
AU CLINICAL DIAGNOSIS
1. Class IV congestive heart failure
2. Coronary artery disease
3. Anemia
4. Atrial fibrillation, paroxysmal
5. Diabetes mellitus
6. History of gangrene of left knee, status post debridement
7. Chronic renal insufficiency
8. Anemia of chronic disease
9. Hyperlipidemia
10. Gastroesophageal reflux disease
11. History of cholecystectomy
12. History of appendectomy
13. 75 pack/year smoking history
14. Hypotension
15. Status post left
ventricular assist device (
AU FINAL DIAGNOSIS
I. Congestive heart failure, status post left ventricular assist device with
intact anastomoses
A. Dilated hypertrophic cardiomyopathy (720 g)
1. Tricuspid valve 13.5 cm
B. Hepatosplenomegaly (liver 2190 g, spleen 495 g)
1. Liver with cardiac sclerosis.
C. Pulmonary congestion and edema (800 g right, 750 g left) with brown
mottled cut surfaces.
1. Focal infarctions of right middle and lower lobes.
D. Bilateral serosanguineous effusions (450 cc left, 50 cc right)
E. Serous ascites (550 cc)
F. Sacral ulcer
II. Atherosclerosis
A. Coronary artery disease, status post single vessel coronary artery
bypass graft with intact anastomoses and patent lumen.
1. Old, calcified septal infarct (6.0 cm).
2. Occlusion of the native left circumflex artery with remote left
ventricular infarction.
3. Occlusion of the native right coronary artery with recent right
ventricular infarction.
B.
Occlusion of the left renal artery ostium by atherosclerotic plaque.
1. Severe atrophy of left
kidney (58 g)
2. Hypertrophic right
kidney (266 g)
C. Arterionephrosclerosis.
III. Surgical absence of the appendix and gallbladder
IV. Incidental findings:
A. Accessory spleen (1.2 cm)
B. Fibrotic thyroid
C. Sigmoid diverticulosis
D. Multiple cortical adenomata of left kidney.
E. Terminal right lower lobe aspiration.
F. Mild centrilobular emphysema.
G. Adrenocortical-nodular hyperplasia.
H. Bile ductular proliferation of hepatic portal triads consistent with
previous biliary obstruction.
I. Pancreatic duct calculus with periductal fibrosis.
AU CASE SUMMARY
CLINICAL HISTORY: The patient was a 59-year-old male with
chronic class IV congestive heart failure admitted on
unit. In the MICU, the patient went into slow
ventricular tachycardia without response from the implanted defibrillator and
was resuscitated. On June 11th, the
patient underwent his left ventricular assist device placement. The patient tolerated the procedure and was
awaiting heart transplantation. On 6/29
he was found in asystole, despite maximum medical intervention and paced rhythm
a sufficient flow could not be maintained.
The patient expired on
At autopsy, a dilated and hypertrophic heart with a left ventricular assist device was identified. The LVAD and valves were intact and lumina were patent. There was evidence of congestive heart failure due to ischemic cardiomyopathy with old left ventricular and septal infarctions and recent right ventricular infarction resulting in hepatosplenomegaly, pulmonary congestion and edema. There were bilateral pleural effusions and ascites. There was significant atherosclerosis of the aorta with occlusion of the left renal artery resulting in severe atrophy of the left kidney with compensatory hyperplasia of the right kidney. There was a sacral decubitus ulcer.
The cause of death was ischemic cardiomyopathy due to atherosclerotic coronary artery disease and diabetes mellitus.
Accelerated atherosclerosis is seen in patients with Diabetes Mellitus and is a major cause of morbidity and mortality. Advanced glycosylation end products are formed by the elevated levels of glucose in the blood stream resulting in adhesion of cholesterol and other lipids in the blood to vascular walls, cross linking of collagen which traps lipid in the vascular walls, confirmation of resistance to proteolytic digestion of these proteins, induction of lipid peroxidation and inactivation of nitric oxides which cause vasodilatation. Diabetes also causes degeneration of cholesterol to a form that is phagocytized by macrophages in the blood stream and deposited at sites of intimal injury. DM also induces hypercholesterolemia and hyperlipidemia compounding the problem. Patients with diabetes have a 2 fold risk over age matched non-diabetics for myocardial infarction and a 100 fold risk of atherosclerosis-induced gangrene of the lower extremities.
Reference:
Cotran, Kumar, Collins "Robbins Pathologic Basis of Disease 6th Ed. 1999, PP
AU GROSS DESCRIPTION
EXTERNAL EXAMINATION: A duly executed permit for autopsy is received, and the body is identified by toe tag on the left hallux. The body length is 174 cm crown-to-heel and 77 cm crown-to-rump. The body is estimated to weigh 220 pounds. The body is that of a normally developed Caucasian male who appears to be the stated age of 59 years. The body habitus is normal. The head circumference is 59.5 cm, the head is normal in size and the shape is symmetric. Hair distribution is normal and the texture is normal. Scalp hair is gray-white and up to 8.0 cm in length. The face is not remarkable. The eyes are normal. The irides are blue-gray and their pupils measure 0.4 cm on the left and right. The ears are normal. The nose is normal. The mouth is edentulous. The neck is normal. The skin shows congestion of the anterior neck and inferior face. There is an incompletely healed midline incision measuring 45.0 cm in length extending from the sternal notch to the umbilicus closed with Steri-strips. The inferior end is erythematous with eschar. There are marked striae on the lower right quadrant of the abdomen. There is a 54.0 cm long scar and 16.0 cm long recent scar on the medial left leg consistent with vein harvesting. The skin of both legs is mottled brown, consistent with venous stasis. There are four scars in the left upper quadrant, ranging up to 1.2 cm in length. There is a 5.5 x 6.0 cm ulcer with a brown crusted base in the sacral region. There is a 2.0 cm open defect in the right upper quadrant through which a tube passes. There is 2+ dependent livor of the back and posterior legs. There is 2+ rigor mortis. Intravenous access lines are found in the right antecubital fossa, the right infraclavicular region, the left antecubital fossa, and the left groin. The chest circumference is 110 cm and the chest is symmetric. The breasts are normal on palpation. The abdominal circumference is 117.5 cm and the abdomen is mildly distended. The back shows the previously described ulcer but is otherwise normal. The external genitalia are normal for circumcised male sex. The extremities are normal.
CENTRAL NERVOUS SYSTEM: A bitemporal incision is performed and the calvarium is removed. The scalp shows edema. The skull is of average thickness. The middle ears are not examined. The dura is normal. The meninges are normal. The cerebral vessels show minimal atherosclerosis. The brain weighs 1210 grams. The convolutions show normal gyri and sulci. The brain and spinal cord are saved for neuropathologic examination.
THORACIC CAVITY: A "Y" incision is made. The subcutaneous fat measures 3.3 cm at the level of the nipples. Organ situs in the thorax is normal. The breasts are normal on sectioning. The pleural surfaces show numerous fibrous adhesions. The portal cavities contain 450 cc on the left and 50 cc on the right of serosanguineous fluid. A pneumothorax is not found. The mediastinum shows numerous fibrous adhesions. The thymus is not identified. Tubes are identified that penetrate the diaphragm and connect to the left ventricle and proximal aorta.
ABDOMINAL CAVITY: A midline incision is made. The subcutaneous fat measures 4.9 cm at the level of the liver. Organ situs in the abdomen is normal. The diaphragmatic dome heights are at the level of the fourth rib on the right and the fifth rib on the left. The liver is 1.0 cm below the right costal margin at the midclavicular line and the spleen is 4.0 cm above the left costal margin at the midclavicular line. There is a left ventricular assist device in the left upper quadrant. Tubes are seen extending from the device through the diaphragm and to the left ventricle and proximal aorta. The peritoneal surfaces show fibrous adhesions, particularly in the area of the left ventricular assist device. The peritoneal cavity contains 550 cc of serous fluid. The retroperitoneum is without lesions.
CARDIOVASCULAR SYSTEM: The heart weighs 720 grams. The pericardial cavity has been disrupted by surgical intervention. The epicardium shows fibrous adhesions and the epicardial fat is of the usual amount. The heart chambers show dilation. The right ventricular thickness is 0.5 cm and the length is 8.5 cm. The left ventricular thickness is 1.5 cm and the length is 8.8 cm. The atrial appendages are free of thrombi. The foramen ovale is closed. The myocardium is soft and brown. There is a 6.0 cm area of fibrous white and calcified myocardium in the interventricular septum with the calcifications most prominent in the left ventricular side, but fibrosis is also evident from the right ventricular side. The endocardium is otherwise thin and translucent. The trabeculae carneae and papillary muscles are normal. The chordae tendineae are normal. The heart valves are thin and pliable. The heart valve ring circumferences are 13.5 cm tricuspid, 9.0 cm pulmonic, 11.2 cm mitral, and 7.8 cm aortic. The coronary arteries show a left dominant pattern with 30% atherosclerosis of all branches and atherosclerotic occlusion of the native left circumflex artery and native right coronary artery. Thrombosis of no vessels is found. There is a coronary artery bypass graft extending from the proximal aorta to the left circumflex artery. The graft is patent. The aorta is elastic and shows 30% atherosclerosis consisting of lipid plaques, calcifications and ulcerations. There is complete occlusion of the left renal artery ostium by atherosclerosis. The remaining branches are patent. The vena cavae are patent.
RESPIRATORY TRACT: The pharynx is without lesions. The larynx is without lesions. The trachea is without lesions. The mainstem bronchi show erythematous mucosa. The right lung weighs 800 grams and the left lung weighs 750 grams. The pleural surfaces show fibrous adhesions, particularly those surfaces adjacent the mediastinum. The lungs are inflated with formalin prior to sectioning. The pulmonary parenchyma shows posterior congestion. Atelectasis is not present. On sectioning, the parenchyma shows no consolidation. Tumor masses and granulomas are not seen. The cut surfaces of the lungs are dark red and variegated brown, and they exude no fluid. Anthracotic pigmentation is marked. The bronchi show erythematous mucosa. The pulmonary arteries do not have pre mortem thromboemboli. The pulmonary arteries have no atherosclerosis. The pulmonary veins are clear.
GASTROINTESTINAL TRACT: The tongue is normal. The submandibular salivary glands are not examined. The esophagus is without lesions. The stomach contains 50 cc of brown fluid and partially digested material. The gastric mucosa shows scattered petechial hemorrhages. The rugal pattern is diminished. The pylorus is patent, and the duodenum is normal. The small intestine is normal. Peyer's patches in the terminal ileum are not prominent. The mucosa is velvety and the folds are normal. The appendix is
absent. The large intestine shows diverticula in the sigmoid region. The mucosa is velvety and haustral folds are normal. The bowel contents consist of a moderate amount of soft brown stool. The mesenteric arteries and veins are normal.
PANCREAS: The pancreas measures 10.0 x 4.0 x 3.0 cm and is the usual size, firm and tan. Fat necrosis is not present. The pancreatic duct is patent with no stones and enters the duodenum at the ampulla of Vater.
HEPATOBILIARY SYSTEM: The liver weighs 2190 grams. The liver capsule is smooth and glistening. The liver edge is blunted. The hepatic parenchyma is soft and brown. Cirrhosis is not present and the lobular pattern is not visible. Tumor masses are not seen. The portal vein is not opened. The hepatic artery and veins are patent. The gallbladder is absent. The extrahepatic ducts and intrahepatic ducts are patent and contain no stones. The ampulla of Vater is normal.
SPLEEN AND LYMPHATIC SYSTEM: The spleen weighs 495 grams. The splenic capsule is smooth and translucent with no lesions. The splenic parenchyma is dark red and soft to firm. The follicular and trabecular pattern is not visible. A small, 1.2 cm, spherical accessory spleen is found. The splenic artery is patent and the splenic vein is patent. The mediastinal and mesenteric lymph nodes are the usual size, gray-tan, soft and up to 1.0 cm in size.
URINARY SYSTEM: The right kidney weighs 266 grams and the left kidney weighs 58 grams. The capsules strip with ease. The cortical surfaces of the kidneys are mottled. There are multiple cortical cysts ranging up to 0.6 cm in greatest dimension on the right side and there are fetal lobulations. The left kidney, which is markedly atrophic, shows multiple white cortical nodules up to 0.5 cm in greatest dimension. The cut surfaces on the right show pale red cortices that are 0.5 cm in thickness. Corticomedullary demarcations are poor. The medullae are red. Cut surfaces on the left show very thin cortex/medulla with no identifiable demarcation. The calyces and pelves contain abundant fatty tissue. The pyramids, calyces and pelves on the right are normal. The ureters are normal and enter the bladder at the trigone. The bladder is the usual size with a thin wall and smooth mucosa throughout. A catheter is present. The bladder contains no urine and no calculi. The urethra is patent. The renal arteries themselves show no atherosclerosis; however, the left renal artery ostium is occluded by severe atherosclerosis. The renal veins are unremarkable.
MALE GENITAL SYSTEM: The prostate is normal in size, is soft, and shows the usual appearance. The seminal vesicles are not examined. The testes are normal in size. On sectioning, they are brown in color and soft in consistency with tubules that string well. The epididymides are normal.
ENDOCRINE ORGANS: The pituitary is the usual size, shape, color and consistency and rests in the sella turcica. The thyroid weighs 33.1 grams and is mildly enlarged. The thyroid has the usual shape and color but a fibrotic consistency. On sectioning, the parenchyma is brown and firm with no nodules. No parathyroid glands are found. The right adrenal gland weighs 11.7 grams and the left adrenal gland weighs 8.6 grams. The adrenals are normal in size with the usual shape, color and consistency. The cortices have the usual appearance. The medullae are normal.
MUSCULOSKELETAL SYSTEM: The body and extremities are symmetric with no malformations. The skeletal muscles are red-brown and there is no evidence for muscle wasting. Bony deformities are not present. Cardiopulmonary resuscitation was performed with no lesions present on the anterior chest. The joints are not examined. The vertebral bone marrow is red and the vertebral bone is normal in consistency.
CASSETTE CODE:
A - sigmoid diverticulum
B - bone marrow
C - mediastinal lymph node and thyroid
D - right adrenal, left adrenal and pituitary
E - right ventricle and right coronary
F - left ventricle and left coronary
G - septum and accessory spleen
H - left kidney and spleen
I - right kidney
J - liver and pancreas
K - left upper lobe
L - left lower lobe
M - right upper lobe
N - right middle lobe
O - right lower lobe
P - vertebrae and septum
Q - nodules on left kidney
AU MICROSCOPIC DESCRIPTION
BONE MARROW: Sections of expressed marrow from the rib demonstrate 30 to 40% cellularity with focal lipogranulomata without evidence of infectious agents or significant lymphocytic cuffing. Histiocytes are vacuolated. The M:E ratio is 3:1 and there is complete trilineage maturation. Megakaryocytes are adequate. Sections of vertebral bone demonstrate unremarkable cortical and trabecular bone.
THYROID: Sections of the thyroid demonstrate variably sized colloid filled follicles arranged with fine fibrous septae. There is no inflammation.
LYMPH NODES: Sections of a mediastinal lymph node demonstrate moderate amounts of the anthracosilicosis and moderate autolysis. The underlying architecture is unremarkable.
SPLEEN: Sections of the accessory spleen demonstrate a normal architecture with mild congestion. Sections of the spleen demonstrate congestion and unremarkable architecture.
PITUITARY: Sections of the pituitary demonstrate the usual nesting of epithelial cells with markedly eosinophilic cytoplasm. There are several small epithelial lined cystic structures at the margin between the anterior and posterior pituitary. The neurohypophysis demonstrates the usual spindle cells with fibrillar interstitium.
ADRENALS: Sections of the right and left adrenals demonstrate slight cortical enlargement by moderate to markedly vacuolated cells. Focally these cells form nodules which are surrounded by a fibrous capsule. There is mild autolysis. In the peri adrenal fat there is mild lymphocytic infiltration and areas of fibrosis.
HEART: Sections of the right coronary artery demonstrate recannulization with three lumina, marked intimal fibrosis and medial hypertrophy. Sections of the left coronary artery submitted demonstrate intimal sclerosis and calcification. The lumen is not apparent. Sections of the right ventricle demonstrate focal wavy fibers, interstitial fibrosis and focal fatty infiltration. There is one focus of myocyte necrosis with balloon degeneration and infiltration by histiocytes and fibroblasts. There are small capillaries forming within this region. Sections of the left ventricle demonstrate moderate interstitial fibrosis with focally dense patches of fibrosis surrounding intramyocardial vessels. Myocytes demonstrate hypertrophy with some box-car nuclei. Focally there is loss of nuclear basophilia. The epicardial fat demonstrates focal fibrosis and increased fibrosis of the epicardial surface. These regions also demonstrate increased inflammatory cells consisting mostly of macrophages and lymphocytes. Sections of the lower inter-ventricular septum demonstrate dense sclerosis with near complete loss of myocytes and focal calcification. The endocardial surface on both the right and left ventricular sides is markedly thickened and fibrotic. Sections of the upper interventricular septum demonstrate marked interstitial fibrosis diffusely throughout. The myocytes are hypertrophied with box-car nuclei. There is focal loss of nuclear basophilia.
KIDNEYS: Sections of the right kidney demonstrate approximately 30% globally sclerosed glomeruli. There is focal interstitial infiltration by lymphocytes and mild interstitial fibrosis. There is moderate to marked autolysis. The intrarenal arteries demonstrate mild intimal fibrosis and medial hyperplasia. Glomeruli remaining demonstrate focal Bowman's capsular sclerosis. The small arterioles demonstrate moderate to severe sclerosis. The tubules within the papillary region demonstrate rare pigmented casts. Sections of the left kidney demonstrate approximately 90% global sclerosis of glomeruli, thickening of arteries and arterioles with sclerosis and thyroidization of the tubules. The medullary region of the kidney is fibrotic and transitional mucosa is focally noted without abnormalities. Sections of the nodules identified on the surface of the left kidney demonstrate well defined clusters of cuboidal cells with a fine fibrovascular stoma. These epithelial cells in one focus demonstrate eosinophilic cytoplasm whereas in
the larger nodule demonstrate a cleared cytoplasm. Both nodules demonstrate focal calcification.
LIVER: Sections of the liver demonstrate moderate autolysis, central vein fibrosis with bridging to portal triads. There is widening of the sinusoids and congestion. The portal triads demonstrate rounding with bile ductule proliferation and little inflammation. There is rare macrovesicular steatosis.
PANCREAS: Sections of the pancreas demonstrate autolysis with a normal underlying architecture and possibly some increase in peri ductular fibrosis. One medium sized duct demonstrates occlusion by calculus with ductular proliferation through the adjacent fatty tissue. Focally, there is amyloid encroaching on islets.
LUNGS: Sections of the lungs demonstrate diffuse mild to moderate congestion, marked interstitial edema and mild thickening of the venules. In the right middle and right lower lobes there is patchy infarction of the pulmonary tissue with loss of nuclei and focal evidence of aspiration with clusters of bacteria and squamous cells. There is diffuse mild centrolobular emphysema and mild anthracosilicosis. There is no evidence of acute pneumonitis.
Hemoglobin A1C
Glucose
Blood Gas: 6/12/- 6/29/2002
|
|
|
|
|
|
|
|
|
|
|
Units |
|
BG type |
Arterial |
Arterial |
Arterial |
Arterial |
Arterial |
Venous
|
Venous
|
Arterial |
Arterial |
|
|
FiO2 |
80
% |
80
% |
100
% |
100
% |
100
% |
100
% |
21
% |
3
L |
4
L |
|
|
Temp |
36.2
C |
36.2
C |
37.6
C |
37.4
C |
37
C |
37
C |
37
C |
38.5
C |
37.8
C |
Deg
C |
|
PH |
7.148
|
7.187
|
7.214 |
7.135
|
6.995 |
7.041
|
6.98
|
7.427 |
7.397 |
|
|
PaCO2 |
30.7
|
32.7
|
34.8
|
44.6
|
29.4
|
52.1
|
56.6
|
42.2
|
45
|
mmHg
H |
|
PaO2 |
115
|
136
|
200
|
207
|
122
|
37.1
|
22.7
|
70.2
|
77.2
|
mmHg |
|
PaO2 corrected for temp |
110.4
|
131.8
|
203.2
|
209.3
|
|
|
|
76.8
|
80.8
|
mmHg |
|
BE |
-17.3
|
-14.9
|
-12.9
|
-13.3
|
-22.6
|
-15.9
|
-17.8
|
3.2
|
2.6
|
mEq/L
H |
|
HCO3 |
10.2
|
11.9
|
13.5
|
14.4
|
6.8
|
13.5
|
12.7
|
27.3
|
27.1
|
mEq/L
H |
|
THb |
9.2
|
8.7
|
7.5
|
6.7
|
6.9
|
7.7 |
8.1
|
8
|
7.7
|
gram%
L |
|
O2Hb |
95.2
% |
97.4
% |
97.3
% |
97.3
% |
93.9
% |
41.5
% |
16.2
% |
92.8
% |
93.2
% |
|
|
COHb |
0.5
% |
0.4
% |
0.9
% |
1
% |
0.5
% |
1.2
% |
0.9
% |
1.6
% |
1.4
% |
|
|
MetHb |
1
% |
0.3
% |
0.9
% |
0.7
% |
0.9
% |
0.3
% |
0.2
% |
0.7
% |
1.2
% |
|
|
Na+ |
146
|
146
|
146
|
146
|
137
|
139
|
138
|
145
|
143
|
mmol/L |
|
K+ |
4.6
|
5
|
4.3
|
4.7
|
6.1
|
6.6
|
5.8
|
4.5
|
4.2
|
mmol/L |
|
Ca++ |
1.42
|
1.47
|
1.52
|
1.5
|
1.7
|
1.49
|
1.59
|
1.55
|
1.49
|
mmol/L
H |
|
Gluc |
67
|
40
|
81
|
97
|
124
|
145
|
145
|
113
|
115
|
mg/dL
H |
|
Lactate |
18
|
15
|
13.8
|
13.7
|
12.7
|
11.3
|
9.6
|
1
|
0.7
|
mmol/L |
|
O2 content |
12.5
|
12.3
|
10.8
|
9.7
|
9.3
|
4.6
|
1.9
|
10.5
|
10.2
|
vol%
L |
|
A-a O2 |
326
|
304
|
354
|
337
|
439
|
501
|
33 |
|
|
mmHg |
|
Allen’s test |
N |
N |
N |
N |
N |
N
|
N
|
N |
N |
|
|
Pb |
637
|
638
|
637
|
637
|
637
|
637
|
637
|
634
|
633
|
mmHg |
|
Hct |
28.5
|
27.2
|
23.5
|
21
|
21.5
|
24.2
|
25.3
|
24.8
|
24.1
|
gm/dL |
|
Date |
6/29 |
6/28 |
6/27 |
6/23 |
6/21 |
6/19 |
6/16 |
6/14 |
6/11 |
6/10 |
Units |
|
WBC |
12.17 |
7.89 |
6.59 |
5.46 |
5.40 |
6.42 |
8.34 |
10.36 |
5.64 |
6.53 |
K/uL |
|
RBC |
3.26 |
3.02 |
3.09 |
3.27 |
3.41 |
3.51 |
3.62 |
3.20 |
2.74 |
4.24 |
M/uL |
|
Hemoglobin |
9.0 |
8.3 |
8.4 |
9.3 |
9.7 |
9.8 |
10.1 |
9.0 |
7.6 |
11.6 |
gm/dL |
|
Hct |
28.4 |
26.6 |
26.7 |
27.5 |
28.4 |
29.3 |
30.0 |
26.3 |
23.0 |
34.9 |
% |
|
MCV |
87.2 |
88.1 |
86.5 |
84.3 |
83.2 |
83.5 |
83.0 |
82.1 |
84.1 |
82.3 |
fL |
|
MCH |
27.5 |
27.5 |
27.2 |
28.3 |
28.3 |
27.9 |
27.8 |
28.1 |
27.9 |
27.3 |
pg |
|
MCHC |
31.5 |
31.2 |
31.4 |
33.6 |
34.0 |
33.4 |
33.5 |
34.2 |
33.2 |
33.1 |
gm/dL |
|
RDW |
18.0 |
18.7 |
18.6 |
18.3 |
18.1 |
18.0 |
17.4 |
17.3 |
16.0 |
16.5 |
% |
|
Platelets |
410 |
147 |
421 |
313 |
283 |
250 |
237 |
202 |
157 |
309 |
K/uL |
|
MPV |
8.1 |
8.9 |
7.5 |
8.6 |
8.6 |
9.3 |
7.6 |
8.0 |
8.1 |
7.5 |
fL |
|
Granulocyte |
74.9 |
|
|
|
|
|
|
|
|
|
% |
|
Lymphocyte |
20.4 |
|
|
|
|
|
|
|
|
|
% |
|
Monocyte |
3.9 |
|
|
|
|
|
|
|
|
|
% |
|
Basophil |
0.7 |
|
|
|
|
|
|
|
|
|
% |
|
Eosinophil |
0.1 |
|
|
|
|
|
|
|
|
|
% |
|
Chemistry Panels |
Sodium |
Potassium |
Chloride |
CO2 |
Anion gap |
BUN |
Creatinine |
Glucose |
|
|
148 * H |
4.9 * |
113 * H |
15 * L |
20 * H |
43 * H |
2.0 * H |
31 * C |
|
|
136 |
4.2 |
110 H |
23 |
3 L |
43 H |
1.3 |
101 * |
|
|
138 |
4.0 |
109 H |
25 |
4 L |
49 H |
1.4 |
72 * |
|
|
137 |
3.6 |
110 H |
23 |
4 L |
53 H |
1.4 |
68 * |
|
|
141 |
3.9 |
112 H |
25 |
4 L |
63 H |
1.6 H |
89 * |
|
|
132 L |
4.3 |
96 L |
28 |
7 L |
73 H |
2.2 H |
106 * |
|
|
134 L |
3.3 |
95 L |
29 |
10 |
76 H |
2.3 H |
126 * |
|
|
136 |
4.0 |
103 |
27 |
6 L |
96 H |
2.9 H |
107 * |
|
|
132 L |
3.7 |
100 |
26 |
7 L |
105 H |
3.5 H |
130 * H |
|
|
131 L |
3.0 L |
93 L |
25 |
13 |
127 H |
4.9 H |
145 * H |
|
|
131 L |
3.1 L |
92 L |
24 |
15 H |
128 H |
5.6 H |
76 * |
Urinalysis 5/24 – 6/24/2002
|
Urinalysis |
Urine Color |
Urine Appearance |
Specific Gravity |
pH |
Protein |
Glucose |
Ketones |
Bilirubin |
Blood |
WBC |
Nitrite |
RBC/hpf |
WBC/hpf |
|
|
Amber |
Clear |
1.016 |
5.5 |
Trace |
Neg |
Neg |
Neg |
Neg |
Trace |
Neg |
|
2/hpf |
|
|
Yellow |
Clear |
1.010 |
5.0 |
Neg |
Neg |
Neg |
Neg |
Small |
Neg |
Neg |
1/hpf |
|
|
|
Yellow |
Hazy |
1.013 |
5.0 |
30 |
Neg |
Neg |
Neg |
Large |
Small |
Neg |
274/hpf |
15/hpf |
|
|
Yellow |
Clear |
1.009 |
5.5 |
Neg |
Neg |
Neg |
Neg |
Neg |
Neg |
Neg |
|
|
|
|
Yellow |
Clear |
1.010 |
5.0 |
Neg |
Neg |
Neg |
Neg |
Neg |
Neg |
Neg |
|
|
Laboratory
ACTH 9
- 52 pg/mL
Alpha-fetoprotein 0
- 15 ng/mL
Alanine
aminotransferase (ALT) 6
- 50 U/L
Albumin 3.5
- 4.6 g/dL
Alkaline
phosphatase 45
- 150 U/L
Ammonia 7
- 27 micromol/L
Amylase,
serum (adult) 30
- 110 U/L
Aspartate
aminotransferase (AST) 15
- 50 U/L
Bilirubin,
total 0
- 1.5 mg/dL
Bilirubin,
direct 0
- 0.3 mg/dL
Calcium 8.8
- 11.0 mg/dL
Carbon
dioxide 20
- 29 mmol/L
Catecholamines,
urine free
Epinephrine 0 - 25
microgm/day
Norepinephrine 0 - 100
microgm/day
Chloride 101
- 111 mmol/L
Cholesterol,
total 100
- 200 mg/dL
Cholesterol,
HDL 0
- 35 mg/dL
Cortisol
(
(
Creatine
kinase 20
- 200 U/L
Creatinine 0.8
- 1.4 mg/dL
Erythrocyte
sedimentation rate 0
- 20 mm/Hr
Estradiol,
female <73
pg/mL (postmenopausal)
30
- 400 pg/mL (normal hormonal cycle)
Ferritin 7
- 340 ng/mL (male)
7
- 75 ng/mL (female)
Gastrin 0
- 100 pg/mL
Glucose 64
- 128 mg/dL
HCG,
serum, quantitative
Male 0 - 5 IU/L
Female 2
- 8 IU/L
Homocysteine,
plasma 4
- 12 micromol/L
Homovanillic
acid (HVA), urine 0
- 15 mg/day
Iron,
serum
Male 50 - 170
microgm/mL
Female 30
- 160 microgm/mL
LDH 105
- 230 U/L
Lipase,
serum 16
- 63 U/L
Metanephrins,
urine, adult
Metanephrine 0 - 300
microgm/gm of creatinine
Normetanephrine 0 - 400 microgm/gm
of creatinine
Phosphorus 2.4
- 4.1 mg/dL
Plasma
renin activity (upright) 0.5
- 3.3 ng/mL/hr
Potassium 3.7
- 5.2 mmol/L
Prostate
specific antigen 0
- 4 ng/mL
Rheumatoid
factor 0
- 20 IU/mL
Sodium 136
- 144 mmol/L
Thyroglobulin
antibody 0
- 2 IU/mL
Thyroid
peroxidase (TPO) antibody 0
- 2 IU/mL
(antimicrosomal antibody)
Thyroid
stimulating hormone (TSH) 0.4
- 5 mU/L
Thyroxine 4.5
- 10.9 microgm/dL
T4,
free 0.9
– 2.3 ng/dL
Total
Protein, serum 6.3
- 8.2 g/dL
Total
Protein, CSF 15
- 45 mg/dL
Troponin
I <0.4
ng/mL; >2 ng/mL consistent with myocardial injury
Urea
Nitrogen (BUN) 7
- 20 mg/dL
Uric
Acid 2.7
- 6.6 mg/dL
Hgb 12 - 16 g/dL
female
13 - 18
g/dL male
Hct 37 - 48 % female
42 - 52
% male
MCH 28 - 33 pg/cell
MCHC 32 - 36 g/dL
MCV 86 - 98 fL
RDW 11.5 - 14.5%
Platelets 150,000 - 300,000/microliter
WBC
count 4300 -
10,800/microliter
PT 12.5 seconds
PTT 26.2 seconds
Fibrinogen 150 - 350 mg/dL
Lymphocyte
subsets
CD4 cells (absolute) 440 - 1600/microliter
CD8 cells (absolute) 180 - 850/microliter
Quantitative
Immunoglobulins
IgA 68
- 378 mg/dL
IgG 768
- 1632 mg/dL
IgM 60
- 263 mg/dL